NLNPhysicalAssessment Flashcards
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Transcript of NLNPhysicalAssessment Flashcards
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Adjust the opthalmoscope to a____________________________ andset the diopter dial to __________.
plain white circle0
Blood pressure should betaken in both arms when?
on f irst encounter, use highernumber arm for recording
Check extraocularmovements by
six cardinal directionsusing H pattern
Corneal ref lect ion should be centered____________________ when you shine a
light direct ly in f ront of the pat ientcentered over the pupils
Extraocular movement testswhich of the cranial nerves
3, 4, and 6oculomotor, trochlear, abducens
Frontal sinuses are located_________________ below eyebrows
Gait would fall under the category of
A) appearanceB) body s tructure
C) behaviorB) body structure
Head circumference ismeasured until age ______. 36 months
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Height - measure in recumbantposition for ages _____.
under 2 (up to 3 ifunable to stand)
Hold otoscope with thumb & f ingersso that __________ aspect of yourhand makes contact with patient ulnar
Inspection look at color, shape,symmetry, position
Integumentary system -inspect skin for
color, moisture, hair pattern,rashes, lesions, edema, pallor
Look through the opthalmoscope and shine thelight into the patient's eye from about
_____________ away. You should see the retinaas a ________________.
2 feetred reflex
Maxillary sinuses are located_____________________ below zygomatic arch
Normal respirations 14-20 breaths/minute
Normal temperaturesOral -
98.6F/37C
+1 for rectal & aural, -1 for axillary
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Objective data observed by nurse
Palpate lymph nodeswith _________
pads of your index andmiddle finger
Palpate skin for temperature, turgor,lesions, edema
Position patient at 20 feet for ______________chart
or at 14 feet for ___________________ pocketcard.
SnellenRosenbaum
Pull ear ______ and_________ for adult up and backPull ear ______ and_________ for child down and back
Sound characteristics ofauscultation
frequency, pitch intensity,duration, quality
Sounds are audiblewithout stethoscope direct auscultation
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Stand 2 feet in front o f patient & have them look in to youreyes
Hold your hands to the s ide ha l f way between you and patientWigg le fingers on one hand
As k patient to ind ica te which s ide they s ee your fingers m ove.Th is is s creens _____________________________________
Visual fields byconfrontation
Subjective data said by clientThe __________________________ of lymph
nodes lies below the sternomastoid muscle andcannot be palpated without
_____________________________________.
deep cervical chaingetting underneath the muscle
To assess temporomandibular joint place the________________________________ directly in
front of the ________________ of each_____________.
t ips of your index f ingerstragus
ear
To percuss the chesthyperextend the ____________ finger of one handand place the _____________________________
firmly against the patient's chest.
middledistal interphalangeal joint
To test visual acuity the patientshould/should not wear glasses shouldUse _______ to assess
skin temperature back of hand (dorsal)
Use ___________ to assesstexture, moisture, areas of
tenderness fingertips
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Use the end or the pad of theopposite middle f inger to f lick with
when percussing the chest. endUse your left hand and left eye to examine the
patient's _____ eye. Use your right hand and righteye to examine the patient's ______ eye.
leftright
Uses stethoscope indirect auscultation
Vitals at 1 yrPulse
Systolic BP11590
Vitals at 10 yrPulse
Systolic BP95105
Vitals at 2 yrPulse
Systolic BP11092
Vitals at 6 yrPulse
Systolic BP10395
Vitals at 6moPulse
Systolic BP13090
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
Vitals at 8 yrPulse
Systolic BP100100
Vitals at birthPulse
Systolic BP14070
alert & oriented would fall under the category of
A) appearanceB) body s tructure
C) behaviorA) appearance
appears clean and wel l -groom ed would fa l l under the categoryof
A) appearanceB) body s tructure
C) behavior C)bronchophony
as k patient to s ay ______________aus cultate luns
Sounds s hould be_________________________________
ninety-ninemuff led & indist inct
if clear this is bronchophony
check accomodation byholding f inger 10 cm f rom pt's nose & askingthem to alternate looking of f to distance & at
f inger. Observe pupillary response
check convergence by moving your f inger toward thebridge of the patient's nose
crackles high pitched similar torubbing hair
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
egophonyAsk patient to say _____ continuously
You should hear __________________. If youhear _____ this is egophony
"ee"muff led "ee"
"ay"
flat or dull pleural effusion or lobarpneumonia
hyperresonant emphysema orpneumothorax
hypertensive crisis >210 systolic, >120diastolic
maintains eye contact would fall under the category of
A) appearanceB) body s tructure
C) behavior C) behaviorno s igns o f acute d is tres s would fa l l under the category o f
A) appearanceB) body s tructure
C) behavior A) appearance
normal healthy lung orbronchitis
normal pulse count for 15 thenx4, if irregular count full minute 60-100 BPM for adult
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
occipital lymph node islocated at base of skull
postaurical lymph nodeis located behind the ear
preaurical lymph node islocated in front of the ear
respiratory sounds are _____pitched
heart murmurs are _____ pitched high, low
rhonchi snoring, gurgling sound
s peech clear would fall under the category of
A) appearanceB) body s tructure
C) behavior C) behaviorsubmandibular lymph
node is located under jaw on side
submental lymph nodeis located under jaw midline
NLN Physical AssessmentStudy this se t online at: http://www.cram.com/cards/2664904
superficial lymph node islocated
over and in front of thesternomastoid muscle
supraclavicular lymphnode is located
angle of sternomastoidand clavicle
tactile fremitussay _____________________
palpate using _______ of handYou should/should not feel vibrations
ninety-nineball
should
tonsillar lymph node islocated at angle of jaw
use bell of stethoscopefor ___ pitched sounds low
use diaphragm of stethoscopefor ___ pitched sounds high
weight & height would fall under the category of
A) appearanceB) body s tructure
C) behaviorB) body structure
wheezes high pitched musical